OMB No. 0581-0189

Exp. 1/31/2027. Destroy previous editions.

TEXAS VALLEY CITRUS COMMITTEE 

901 Business Park Drive, Suite 400 

Mission, Texas 78572

Telephone: (956) 581-2190

CERTIFICATE OF PRIVILEGE NO. __________

I, the undersigned, hereby certify to the Secretary of Agriculture and to the Texas Valley Citrus 

Committee that I have read, fully understand, and will comply with, the foregoing rules that govern the 

handling of citrus for processing or for manufacturing for conversion into specified by-products, relief or 

charity. I further understand that noncompliance is a violation of the Agricultural Marketing Agreement 

Act, and is subject to a fine of up to $3,147 for each violation.

By: ______________________________ ___________________________ ____________

Name (please print) Signature Date

Firm Name: ___________________________________ Title:____________________________

Address: ____________________________________________________________________________

Mailing Address, City, State, and Zip Code

Physical Address (if different than mailing address):

Phone: _______________________________ Email: 

Person in charge of Special Purpose forms: _________________________________________________

Purpose of Shipments:  Processing  Relief/Charity  Otherwise Diverted ______________

(check applicable boxes)

Where will shipments originate? _________________________________________________________

List Names and Addresses of Consignees below:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

APPROVED BY: ______________________________________ DATE:____________________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information 

unless it displays a valid OMB control number. The valid OMB control number for this information collection is OMB 0581-0189. The time required to complete 

this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and 

maintaining the data needed, and completing and reviewing the collection of information.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and 

employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, 

gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance 

program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all 

programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for 

program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 

720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in 

languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at 

http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information 

requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of 

Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: 

program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.